Data Omission by Physician Trainees on ICU Rounds.

Area of Science:

• Medical Education
• Patient Safety
• Clinical Informatics

Background:

• Incomplete patient data can lead to misdiagnosis and medical errors.
• The extent to which interprofessional rounding teams appraise patient data during clinical decision-making is not well understood.
• Physician trainees are primary presenters during daily rounds in many ICUs.

Purpose of the Study:

• To measure the frequency of data omission by physician trainees from prerounding notes and verbal presentations during ICU rounds.
• To identify factors influencing data omission during clinical rounds.

Main Methods:

• An observational study was conducted in a tertiary academic medical ICU.
• 157 patient presentations were audited, comparing electronic health record data with trainee artifacts and audio recordings of rounds.
• Data omissions were quantified across nine domains.

Main Results:

• All 157 presentations included data omissions.
• 22.9% of data were missing from artifacts and 42.4% from verbal presentations.
• Omission frequency varied by data type, with prior omission from artifacts predicting verbal omissions.

Conclusions:

• Verbal appraisal of patient data during academic ICU rounds is highly incomplete.
• Improved trainee oversight, education, and electronic health record tools are necessary.
• Novel academic rounding paradigms may help mitigate medical errors stemming from data omission.